State governments don't always use the legislative route to bring about change. Two states recently took administrative steps to strengthen the hand of patients in managed care plans.In New Jersey, the Department of Health released HMO draft regulations that cover a host of issues including recertification, quality and access, the appeals process and financial standards. The rules represent the first revision of the state's HMO regulations in more than 20 years.
Under the proposed rules, HMOs would have to be recertified every three years. In the health access area, only physicians would be authorized to deny or limit medical services. HMOs also would be required to disclose to the state the financial incentives they offer participating physicians to make them hold the line on medical expenses. New York state is considering adopting a similar disclosure rule.
For members dissatisfied with a New Jersey HMO's decision to deny or limit coverage, an external appeals process would be established. After a public comment period, the rules are expected to become final in May. HMOs in the state worry that they are being singled out for more stringent regulations than those applied to other kinds of health plans.
In Texas, the insurance commissioner recently issued "fair play" rules for patients in managed care plans at the request of Governor George W. Bush, son of the former president, who earlier had vetoed a "patient protection" bill that was backed by the state medical association.
Effective Jan. 1, the regulations require that patients receive "reasonable" advance notice before an HMO drops their doctor or dentist from its provider network. The rules also prohibit HMOs from using any financial incentives that induce providers to limit "medically necessary" services. Retaliation against insured individuals or against physicians "reasonably complaining on behalf of their patients" also is prohibited.
The rules provide a review procedure for physicians and dentists who are removed from a plan's provider list. Texas Insurance Commissioner Elton Bomer announced the new rules with the hope that they would "smooth the rough edges of managed care without undercutting its strengths.
"Texans will see that we can give patients and providers a fair shake while preserving managed care's effectiveness in containing health care costs," added Bomer.
The growing trend to mandate permission for women patients covered by managed care plans to have direct access to their Ob/Gyns is expected to continue in the 1996 state legislative session. Eight states passed Ob/Gyn laws in 1995, and more will follow, says Dan Stech, a field representative in the state government relations office of the Englewood, Colo.-based Medical Group Management Association. Connecticut, Louisiana, Maryland, Mississippi, North Carolina, Oregon, Utah and Washington enacted laws that allow women to see their Ob/Gyns without going through a gatekeeper physician first.
In general, the legislation permits women to choose an Ob/Gyn participating in a managed care plan as their primary care doctor, and to see that physician at least once a year. "This is a fairly popular legislative initiative," says Stech.
Of course, some insurance companies allow direct access to Ob/Gyns even without state laws requiring them to do so. Critics of the move to guarantee such access by legislation say these laws could set a troubling precedent for managed care organizations as other specialties seek similar legislation to assure patient access.
— Joan Szabo